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Research Training in Psychiatry Residency: Strategies for Reform 6 Future Directions for Promoting the Development of Psychiatrist-Researchers This report has described the importance of early research training for the development of independent patient-oriented researchers in psychiatry. It has also reviewed regulatory, institutional, and personal factors that are relevant to such training. This final chapter addresses three overarching issues that the committee believes are important for the future of psychiatric research training. The first is the importance of having better and more data regarding the research workforce and society’s need for psychiatrist-researchers. The second is the need for more outcome data in ongoing and novel patient-oriented research training efforts. These outcome data should describe, at a minimum, the frequency with which a given strategy yields a bona fide researcher. Third is the need for a national effort to promote, implement, and monitor the training of psychiatrist-researchers. To be effective at recruiting researchers and raising financial support for the costs of training, such an effort should be directed at medical students and residents on the one hand and society at large on the other. The chapter ends with an overarching recommendation addressing these needs. WORKFORCE ESTIMATES AND MONITORING As discussed in Chapter 1, the committee had considerable difficulty finding data regarding the current size of the psychiatrist-researcher workforce, as well as projected needs. Although it is clear that psychia-
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Research Training in Psychiatry Residency: Strategies for Reform trist-researchers have made and continue to make contributions to patient-oriented investigations, it is not clear how many psychiatrist-researchers need to be trained to replace those who are retiring or otherwise leaving the workforce. It is also not known how many additional psychiatrist-researchers are needed given the increasing importance of mental health to the nation’s overall health. Part of the problem is in establishing a precise definition of a psychiatrist-researcher. Is a psychiatrist-researcher someone who does research 1 day a week (Pincus et al., 1995), or must research be the primary professional activity (AAMC, 2002b)? Are psychiatrist-researchers those who serve as principal investigators on federal research grants, or is it sufficient for them to serve as consultants on late-phase clinical trials? In The Crisis in Clinical Research, Ahrens (1992) argues that the latter type of research (e.g., trials of emerging drugs and devices) will readily attract capital resources, and thus particular attention should be directed to more innovative types of research that will expand our knowledge of the disease process in more complex ways. In any case, characterization of the current and desired psychiatrist-research workforce is essential to determine who should be trained and in what methods. Determining the future need for researchers is more difficult than determining the numbers and types of current researchers. Workforce needs estimates in medicine are generally difficult to calculate. Measuring the physician workforce with regard to the projected needs of various specialties is extremely difficult, if not impossible, to do with great precision (Council of Graduate Medical Education [COGME], 2000). As recently as 1996, a serious oversupply of physicians was predicted (Knapp, 2002), but by June 2002, the Association of American Medical Colleges (AAMC) had released the following policy statement: After reviewing the range of studies over the past several decades…the AAMC has concluded that no definitive conclusion can be drawn about the adequacy of the workforce, nor can specific recommendations be made about the rate of supply of new physicians (Knapp, 2002:1078). A recent National Research Council (NRC) report on the training of junior biomedical and behavioral scientists calls for increasing the numbers of physician-researchers based on a relative decline in those numbers and on the following logic:
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Research Training in Psychiatry Residency: Strategies for Reform Because those who interact with patients often bring great understanding and awareness of the health needs of the public to clinical research, the diminishing role played by physicians affects the capacity of the clinical research workforce to sustain a program of research that addresses the nation’s needs (NRC, 2000:51). As sound as that logic may appear, it would be strengthened by studies quantitatively demonstrating the public health impact of patient-oriented physician-investigators. As described in Chapter 1, the great burden of mental illness and the unique skills of psychiatrists together allow one to conclude that a low number of psychiatrist-researchers is detrimental to the nation's overall ability to cope with mental illness. However, this is indirect evidence at best, and thus the committee believes it will be important for psychiatry to demonstrate more directly the importance of training greater numbers of researchers to justify the resources necessary for that training. The committee had difficulty identifying published studies that explicitly quantify the benefits associated with research conducted by psychiatrists. However, we found one study that demonstrated impressive cost savings associated with psychiatric research more generally (Silverstein et al., 1995). Additionally, the committee performed two rudimentary assessments of recent publications first-authored by psychiatrists, and job listings in psychiatric research, both of which indicated the importance of or demand for psychiatrist-initiated research. These types of reviews offer models for more thorough investigations in the future (see Box 6-1 for details). An alternative hypothesis to the idea that there is an increasing gap between mental health needs and the number of psychiatrist-researchers is that there is instead, or additionally, a shortage of other professionals in mental health and mental health research (e.g., clinicians, psychologists, social workers, neuropharmacologists). Although such workforce estimates are beyond the committee’s charge of identifying strategies to increase the numbers of psychiatrists engaged in research, the committee believes sound workforce estimates are necessary for planning and implementing a credible training effort. At least one recent study takes a national look at the composition of the clinical mental health workforce and finds that while the numbers of psychiatrists in that workforce have increased markedly (by 15 percent) since the early 1990s, the numbers of psychologists and social workers have increased at even higher rates (37 percent and 18 percent, respectively) (Scheffler and Kirby, 2003). Similar trends are implied by studies of physician-investigators and Ph.D.-
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Research Training in Psychiatry Residency: Strategies for Reform investigators seeking support from the federal government (Zemlo et al., 2000). It is not well known, however, how psychiatrist-researchers have fared in recent years, and to what extent psychologists and other non-physician mental health practitioners have successfully filled the associated gaps in psychiatric patient-oriented research. The Council on Research of the American Psychiatric Association (APA) has established the concrete goal of doubling the number of psychiatrist-researchers by 2012. However, that goal is based largely on impressions of leaders in the field, including those at the National Institute of Mental Health (NIMH), and on the broader decline in the numbers of all physician-investigators (personal communication, J. Greden, APA Council on Research, July 26, 2002). As the goal is based on neither a precise estimate of need nor trends specific to psychiatry, its importance may not be credible to decision makers outside of psychiatry. BOX 6-1 Three Studies Suggesting the Need for Psychiatrist-Researchers Analysis of cost-savings. Silverstein and colleagues recently gathered cost-savings data from 19 medical and dental studies and found that biomedical innovations of the last 50 years have yielded approximately $69 billion in overall savings per year. They also found that nearly half of those savings ($33 billion per year) were the result of enhanced pharmacological therapies for patients suffering from schizophrenia or manic-depressive illness (Rosenberg, 2002; Silverstein et al., 1995). Direct assessment of psychiatrist-initiated scholarship. In 2001, NIMH established a bibliography of brain and behavioral research studies for a White House Conference on mental health (NIMH, 2001b). A review of a randomly-selected subset (62 of 249) of first authors from that bibliography found that 50 percent were psychiatrists. The same bibliography of 249 citations was further reviewed by 13 lay reviewers with no connection to professional mental health practice and no knowledge of the aim of this IOM report. These lay reviewers were asked to peruse the bibliography and select articles they viewed as most important to the future of public mental health. More than half of these reviewers identified 10 articles as “important” and “compelling,” and 6 of these were first-authored by psychiatrists. This informal assessment demonstrates that psychiatrists have a substantive presence as lead scholars on projects considered valuable to NIMH and the broader public as well. Survey of the job market. Selected web-based issues of Science and of Academic Physician and Scientist were reviewed for faculty research
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Research Training in Psychiatry Residency: Strategies for Reform position advertisements. The review took place on five separate days between late November and mid-December 2002, and late May and early June 2003. Web searches within each journal’s job postings were done using the keywords corresponding to selected specialties (e.g., “psychiatry,” “internal medicine”). Each position announcement was read to see whether research activity was part of the professional responsibilities involved and whether an M.D.-equivalent status was required. This review found 119 physician-researcher positions that translated into the following numbers per 10,000 practitioners in each field: psychiatry, 4.3 (n = 20); pediatrics, 3.9 (n = 25); internal medicine, 3.5* (n = 66); and neurology, 6.7 (n = 8). There are at least two important limitations to this survey. First, the sample size is very small, in part because the sample time was short. Second, it is improbable that the review assesses all or even the major sources of job openings for physician-researchers. A better assessment would involve polling department heads and reviewing specific trade journals and periodicals (e.g. for psychiatry, Archives of General Psychiatry or Psychiatric News). Nevertheless, the implication of this limited survey is that the demand for psychiatrist-researchers is at least as strong as that demand in other medical specialties, with the possible exception of neurology, another discipline focused on the clinical neurosciences, but one that is only one-quarter the size of the psychiatric workforce. * Internal medicine in this survey included general internal medicine, cardiology, gastroenterology, geriatric medicine, hematology, infectious disease, nephrology, oncology, pulmonology, and rheumatology. OUTCOME DATA IN RESEARCH TRAINING The committee also experienced difficulty in obtaining outcome data regarding the success of national and local programs at training productive researchers. Outcome research in medical education is lacking at even the largest of medical institutions. A recent report of the Commonwealth Fund Taskforce on Academic Health Centers (2002) concludes that even at academic health centers, there is a lack of outcome data on effective education methods for training medical students and residents. Some programs (e.g., K23, K30; see Chapter 4) are admittedly too new to provide meaningful outcome data. However, it is the committee’s strong impression that most programs do very little follow-up on residency or fellowship graduates to assess their professional activities. Although institutions and programs often make some estimate of how many researchers emerged from their educational efforts, the majority do not
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Research Training in Psychiatry Residency: Strategies for Reform appear to differentiate between academic educators and academic researchers or between patient-oriented and basic researchers. Consequently, it is unclear what constitutes a “successful” research training program. Indeed, an informal outreach to training programs yielded a variety of different indices of success with regard to research training (see Chapter 4 and Appendix C for further details). A standardized framework for assessing training programs is therefore needed to provide data on which strategies/programs are effective and which are not. Goldman and Williams (2001) have created a generic framework that could be applied to training inputs and outputs on a national and local basis. This framework is designed to help NIH with its data collection efforts and to “identify a range of possible policies and possible impact” of biomedical research (Goldman and Williams, 2001:4). This particular framework is offered as an example, not as an endorsement of its utility compared to other existing techniques for program evaluation. Whatever framework is used, the committee believes strongly that qualitative and quantitative indices of research output by those who receive training or grant support should be periodically assessed to validate the effectiveness and impact of these programs and to consider ways to improve such research support mechanisms. The March of Dimes Birth Defect Foundation recently published an ambitious evaluation of their “Starter Scholar Research Award” grant program (Mavis and Katz, 2003). The evaluation reviewed the 10-year post-application, research productivity of 250 successful and 195 rejected applicants from the mid-1980s. Grant recipients were more prolific than non-recipients in terms of the number federal grant awards received and the number of publications produced. Additionally, awardee publications were cited twice as often as those from non-awardees (119 citations per paper per year, versus 48). Given that 84 percent of these awardees received at least one federal research grant, this study indicates that the March of Dimes has been quite successful at selecting applicants with future research potential. The study also found that successful applicants were more likely to be from prestigious institutions. Like many reports of this nature, however, this study does not offer any analyses that could be used to infer how the program might be expanded or improved to attract or train greater numbers of, and more productive, awardees. Data on research training obtained by the committee typically focused on individual-trainee success stories with less frequent mention of those who failed to develop into researchers. These latter individuals arguably represent the most important group for follow-up study as they are a logical source of information regarding barriers to more efficient
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Research Training in Psychiatry Residency: Strategies for Reform research training. It is obvious to the committee that such data are lacking for at least two reasons. First, success is difficult to define, since the quality of research is not necessarily captured by readily available indices, such as federal funding success or a tally of publications. Second, it is a potentially sensitive matter to contact individuals and programs regarding their “failures.” A strong indication of this point comes from the March of Dimes review described above. As part of their assessment, Mavis and Katz (2003) sent a self-administered survey to all identified applicants. Responses to that survey came from 77 percent of the applicants who had succeeded at securing funding, but from only 28 percent of those who had failed. The failed applicants appear to have been far more reticent about their professional activities, perhaps because they were embarrassed or because they did not believe the survey to be valuable for their particular career objective. Whatever the case, to the extent that funders and association policy analysts want to identify ways of increasing the quality and quantity of grant applicants, they need to conduct evaluations that provide both endogenous (e.g., trainee opinions) and exogenous (e.g., grant priority scores, supervisor evaluations, online databases) information regarding former research trainees in at least three groups: (1) those who fail to achieve initial success, (2) those who opt out of research careers after early success, and (3) those who succeed and fail in categories of importance to the funder (e.g., patient-oriented research). NATIONAL COORDINATING EFFORT As described throughout this report, but especially in Chapters 3 and 4, the committee found that there are currently many professional societies and other stakeholders in mental health and psychiatry that are interested in and/or developing strategies to enhance patient-oriented research training for psychiatrists. As mentioned in Chapter 3, the American Academy of Child and Adolescent Psychiatry has a task force that has already drafted a research-oriented residency training schedule. The American Board of Psychiatry and Neurology (ABPN) and the Psychiatry Residency Review Committee (RRC) have been involved in such efforts, and leaders and members from those regulatory bodies appear to be interested in advancing research training during psychiatric training. Individual chairs and division heads also appear to believe unanimously that research training in psychiatry is important. The debate rests in how to make time and provide resources for implementing such activities given the demands and costs of clinical training and certification.
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Research Training in Psychiatry Residency: Strategies for Reform OVERARCHING RECOMMENDATION Combining the apparent consensus on the importance of research training for psychiatrists with the conclusion that workforce estimates and outcome data are limited, the committee makes this final overarching recommendation: Recommendation 6.1. The National Institute of Mental Health should take the lead in organizing a national body, including major stakeholders (e.g., patient groups, department chairs) and representatives of organizations in psychiatry, that will foster the integration of research into psychiatric residency and monitor outcomes of efforts to do so. This group should specifically collect and analyze relevant data, develop strategies to be put into practice, and measure the effectiveness of existing and novel approaches aimed at training patient-oriented researchers in psychiatry. The group should have direct consultative authority with the director of the National Institute of Mental Health, and also should provide concise periodic reports to all interested stakeholders regarding its accomplishments and future goals. NIMH should take the lead in implementing this recommendation by providing coordinated oversight of efforts to create a regular (e.g., annual) forum that convenes those interested in psychiatric research; furnishing financial resources for this forum to collect workforce and outcome data; and funding pilot initiatives to test potential training solutions. The seeds of such a forum have already been sown by the APA Council on Research, which is working to build a consensus on research training strategies in psychiatry that includes a broad range of stakeholders, such as NIMH, the Psychiatry RRC, and the ABPN. The council’s current approach is to build a consensus on research training in psychiatry, mainly through outreach and communication (personal communication, J. Greden and M. Asher, APA Council on Research, August 2002). It is the committee’s view that some actual training programs, as well as workforce assessment and outcome research, should be added to this forum’s effort. Those activities would obviously require time and resources that could be furnished by NIMH, but resources should also be provided by foundations, industry, professional societies, and other enti-
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Research Training in Psychiatry Residency: Strategies for Reform ties with interest in such a consensus effort to develop best practices in psychiatric research training. An example of a coordinated national research-training effort comes from pediatrics. More than a decade ago, seven national pediatric organizations, including the American Board of Pediatrics, the American Academy of Pediatrics, the Association of Medical School Pediatric Department Chairs, and the Association of Pediatric Program Directors, created the Federation of Pediatric Organizations and began meeting twice annually to deliberate issues of mutual concern and interest. Following the publication of a report on the future of pediatric education, the federation formed a standing group, the Pediatric Education Committee, to implement the recommendations of that report (Simon et al., 2000). That committee, which has research requirements as a major agenda item, is supported financially by contributions from all parent societies and has a budget to fund a national director and office. Although such planning and evaluation require resources, it is the committee’s impression that a considerable amount of data can be collected with slight modification to data collection efforts already in place at NIMH (through the grant application system) and the Accreditation Council for Graduate Medical Education (ACGME) (through the accreditation process). These datasets could be mined on a regular basis to determine programmatic and individual successes regarding research productivity and research training. The proposed coordinating body could help identify what variables will be most useful for review in an effort to determine how best to evaluate patient-oriented research training in U.S. psychiatry. Finally, it should be reiterated here that psychiatry, in working to increase its presence in patient-oriented research, should collaborate closely with other mental health practitioners and researchers who share the field’s professional goals and who furthermore have historically been extremely valuable colleagues and mentors to psychiatrist-researchers. Another resource and potential model for a national body focused on research training in psychiatry is the Institute of Medicine’s (IOM) Clinical Research Roundtable. The roundtable brings together leaders across academic medicine—including university, government, and industry clinical administrators and researchers—to discuss ways of promoting clinical research. It hosts seminars on clinical research and maintains a website that links researchers at all levels to funding sources and other information about clinical research careers. The roundtable is also involved in data collection efforts (e.g., surveys and focus groups) aimed at characterizing the size and scope of the clinical research workforce (IOM, 2002a; Sung et al., 2003).
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Research Training in Psychiatry Residency: Strategies for Reform In summary, the present report characterizes the current state of research training in psychiatry and makes suggestions for enhancing this training. In carrying out its charge from NIMH, the committee was able to gather some data to support the underlying premise that more psychiatrist-researchers are necessary, but hard data in support of that contention were difficult to find. Similarly, the committee uncovered numerous descriptions, both within and outside of psychiatry, of patient-oriented or clinical research training methods. Again, however, hard data on this issue were difficult to find. Specifically, while considerable data on physician-researchers are now available, there is a paucity of data on the subgroup of patient-oriented psychiatrist-researchers. Additionally, effectiveness data are lacking on various educational approaches and how those approaches compare with one another or with nonpedagogical barriers to and incentives for research careers (e.g., personal finances, lifestyle concerns, drive). Finally, the committee was encouraged to find that many national organizations and individual departments in psychiatry are interested in enhancing early-career research training. All of these observations support the importance of establishing an ongoing national effort to develop, implement, and evaluate programs devoted to furthering that goal. Given the compelling issues posed by mental illness and the techniques now available to address those issues, such an endeavor should be exciting and rewarding for all who become involved.
Representative terms from entire chapter: